Please Note: NEE Commonwealth will close for training on December 15, from 8 am - 11 am; NEE Roslindale will close for training on December 15th from 8 am - 12 pm

For Patients

Schedule an Appointment

Use this online form to request an appointment at New England Eye Commonwealth or New England Eye Roslindale. A representative will contact you to confirm your information and assist with scheduling.

Patient Information

First Name*

Last Name*

Address*

Address 2

City*

State*

Zip*

Phone*

Email*

Note any accommodations needed for communication.

DATE OF BIRTH

DOB Month*

DOB Day*

DOB Year*

Health Insurance

Insurance Provider*

Insurance ID

Subscriber's Name (if different)

Subscriber DOB Month

Subscriber DOB Day

Subscriber DOB Year

Additional Insurance Policy

Additional Policy ID

Appointment Request Information

Preferred Location*

Preferred Appointment Month*

Preferred Appointment Day*

Preferred Appointment Time

Morning

Afternoon

Eye Care Services

General Eye Care

Eyeglasses

Pediatric Eye Care

Contact Lenses

Low Vision

Vision Therapy

Optional

Is this your first time at New England Eye?

Yes

No

Appointment For

How did you hear about New England Eye?

If applicable, please enter the human resources or benefits department who referred you.

Comments

Confidentiality Notice

The appointment request form requires you to provide information that is needed to complete your request for an appointment and shall be utilized by New England Eye only for the purpose of helping you secure an office visit. Your information will be transmitted by e-mail and will not be secured by encryption software. By completing and sending the form you accept the risk of sending confidential information via e-mail and agree not to hold New England Eye or any of its affiliates, employees or agents liable for any damages you may incur, directly or indirectly, as a result of the transmittal of your information. You are welcome to telephone New England Eye to make your appointment.